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Acute transmural myocardial ischemia caused by severe emotional stress

Clinical case


Weihs Valerie, Weihs Wolfgang, Huber Kurt

Educational Resource:

Figure 1. 12-lead ECG in the acute phase.
Figure 2. Coronary angiography revealing normal epicardial arteries (A=LCA, B=RCA).
Figure 3. Echocardiography in the acute phase (A) and after 12 days (B). Apical 4-chamber view in systole.
Figure 4. Speckle tracking in the acute phase (A) and after 12 days (B). Bulls-eye-view.

Learning objectives

  •  Not every typically presenting STEMI is by definition a STEMI
  • Emotional stress as trigger is not always detectable in so-called stress-induced cardiomyopathy
  • Wall motion abnormalities usually disappear after some weeks in stress-induced cardiomyopathy
  • Urgent diagnostic catherization is important for diagnosis
  • Takotsubo-syndrome is an equivalent name for stress-induced cardiomyopathy


We describe a rare case presenting as ST-elevation myocardial infarction (STEMI) after emotional stress at our emergency department. Despite clear clinical signs of STEMI including massively elevated troponin and easy to detect wall motion abnormalities by an acutely performed echocardiogram coronary arteries were free of stenoses or thrombus. Such cases are rare but increasingly diagnosed due to better methods and a better knowledge of this disease.

A 69-year-old woman with a history of bipolar disorder was transferred to the interventional cardiology department from the neuropsychiatric department after an acute psychotic episode of unknown cause presenting with ECG abnormalities. The physical examination showed 115 bpm heart rate and 130/80 mmHg arterial pressure. Heart sounds were tachycard and regular, with no murmurs. The lung auscultation was normal, lower extremities showed no sign of edema. An ECG examination revealed Sinustachycardia and ST elevation in leads II, III, aVF, V3-V5 (Figure 1). Cardiac enzymes were elevated: Troponin I 7.250 ng/ml (ULN 0.160 ng/ml), CPK 491 U/l (ULN 140 U/l) and CK-MB 46 U/l (ULN 24.0 U/l).
Question 1
What is the most reliable diagnosis?


As ECG changes and elevation of cardiac biomarkers were indicative for an acute ST-elevation myocardial infarction, the patient received immediately an acute coronary angiography, where normal coronary arteries with no obstructive lesion or angiographic evidence of acute plaque rupture could be seen (Figure 2).
Question 2
What is the most possible differential diagnosis for an acute myocardial infarction in this case?


A transthoracic echocardiogram revealed akinesia in all apical segments of the left ventricle (apical ballooning) with severely reduced left ventricular ejection fraction (<30 %) (Figure 4). Speckle tracking confirmed visual assessment of the regional dysfunction and showed a reduced maximal longitudinal strain in all segments of the left ventricle, except for the basal inferoseptal and basal anterolateral segment. Global longitudinal strain was severely reduced (-7.0%).
A control echocardiography after 12 days showed rapid improvement of the heart failure with normal systolic function and recovery of the regional wall motion abnormalities only with a discreet hypokinesia in the apical region (Figure 3 & Figure 4).
Question 3
What is the most important symptom for the diagnosis of a Takotsubo syndrome beside normal coronary arteries?



This case report shows a typical case of Takotsubo syndrome. It is characterised by acute onset of left ventricular dysfunction, accompanied by ECG changes and elevation of cardiac biomarkers indicative for an acute myocardial infarction (2-12). A preceding acute and severe stress event is often present (either physical or emotional) (11, 12). No obstructive stenosis in epicardial coronary arteries or angiographic evidence of plaque rupture can be seen in acute coronary angiography. Typically regional left ventricular wall motion abnormalities in the apical region (apical ballooning), that extend beyond a single coronary artery distribution are shown with cardiac imaging (eg. ventriculography, echocardiography, cardiac MR). Previous studies have defined 4 different types of Takotsubo Syndrome according to different regional wall motion abnormalities (12). As the left ventricular dysfunction is transient, all pathological findings resolve within a few days to weeks, but there seem to be cases with a delayed recovery of the left ventricular dysfunction (11, 12). The Takotsubo syndrome affects in most cases elderly women, with no history of cardiovascular diseases. Up to now, the pathophysiology of this increasing clinical syndrome remains still unclear.


1. Song BG, Chun WJ, Park YH, et al. The clinical charac- teristics, laboratory parameters, electrocardiographic, and echocardiographic findings of reverse or inverted takotsubo cardiomyopathy:comparison with mid or apical variant. Clin Cardiol 2011; 34: 693–699.
2.  Kurowski V, Kaiser A, von Hof K, , Killermann DP, Mayer B, Hartmann F, Schunkert H, Radke PW. Apical and midventricular transient left ventricular dysfunction syndrome (Tako-Tsubo-Cardiomyopathy). Frequency, mechanism, and prognosis. Chest 2007;132:809-816
3. Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Koike H, Sasaka K. The clinical features of takotsubo cardiomyopathy. Q J Med 2003;96:563-573
4. Akashi YJ, Musha H, Kida K, Itoh K, Inoue K, Kawasaki K, Hashimoto N, Miyake F. Reversible ventricular dysfunction takotsubo cardiomyopathy. Eur J Heart Fail 2005;7:1171-1176
5. Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, Yoshiyama M, Miyazaki S, Haze K, Ogawa H, Honda T, Hase M, Kai R, Morii I; Angina Pectoris-Myocardial Infarction Investigations in Japan. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol 2001;38:11-18
6. Park SM, Prasad A, Rihal C, Bell MR, Oh JK. Left ventricular systolic and diastolic function in patients with apical ballooning syndrome compared with patients with acute anterior ST-segment elevation myocardial infarction: a functional paradox. Mayo Clin Proc 2009;84(6):514-521
7. Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, Rihal CS. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004;141:858-865
8.  Elesber AA, Prasad A, Lennon RJ, Wright RS, Lerman A, Rihal CS. Four-year recurrence rate and prognosis of the apical ballooning syndrome. J Am Coll Cardiol 2007;50:448-452
9. Hurst RT, Askew JW, Reuss CS, Lee RW, Sweeney JP, Fortuin FD, Oh JK, Tajik AJ. Transient midventricular ballooning syndrome. A new variant. J Am Coll Cardiol 2006;48:579-583
10. Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, Maron BJ. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circ 2005;111;472-479
11. Sharkey SW, Windenburg DC, Lesser JR, Maron MS, Hauser RG, Lesser JN, Haas TS, Hodges JS, Maron BJ. Natural History and Expansive Clinical Profile of Stress (Tako-Tsubo) Cardiomyopathy. J Am Coll Cardiol 2010;55:333-341
12. Weihs V, Szuecs D, Fellner B, Eber B, Weihs W, Lambert Th, Metzler B, Titscher G, Hochmayer B, Dechant C, Eder V, Siostrzonek P, Leisch F, Pichler M, Pachinger O, Gaul G, Weber H, Podzeck-Schweighofer A, Nesser HJ, Huber K. Stress-induced cardiomyopathy (Tako-Tsubo syndrome) in Austria. Eur H J: ACC 2013;2:137-146